<div class="container">
  <div class="bg-putih">

    <div class="jdl-page">
      <?php echo $judul; ?>
      <div class="clearfix"></div>
    </div>

    <?php echo display_flash(); ?>

    <?php echo form_open("data_riwayat_pasien/r_penyakit_add/$pasien[KdPasien]", array('class' => 'form-horizontal', 'role' => 'form', 'id' => 'form')); ?>
      <div class="form-group">
        <label class="col-xs-2 control-label">Nama Pasien</label>
        <div class="col-xs-10">
          <input type="hidden" value="<?php echo $pasien['KdPasien'] ?>" name="kode"/>
          <input class="form-control input-sm" type="text" disabled="disabled" value="<?php echo $pasien['Nama']." ( ".$pasien['KdPasien']." )" ?>">
        </div>
      </div>

      <div class="form-group">
        <label class="col-xs-2 control-label">Penyakit</label>
        <div class="col-xs-10">
          <input name="penyakit" class="form-control input-sm" type="text"/>
        </div>
      </div>

      <div class="form-group">
        <label class="col-xs-2 control-label">Keterangan</label>
        <div class="col-xs-10">
        <textarea class="form-control" name="keterangan"></textarea>
        </div>
      </div>

      <input type="submit" name="btn_add_r_penyakit" value="Tambah Data" class="btn btn-sm btn-primary" />
    <?php echo form_close(); ?>
  </div>        

  <div class="clearfix"></div>
</div>
    </div> <!-- /container -->